Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women

Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation ("disorders of extreme stress not otherwise specified"; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.     

Mitral valve prolapse syndrome as cause of sudden death in young adults

Mitral valve prolapse syndrome (MVPS) is a relatively common disorder of the mitral valve and most cases take a benign clinical course. Only a subset of patients develop severe clinical symptoms such as arrhythmia, insufficiency of the mitral valve or infective endocarditis. As a consequence, sudden death might occur in these patients, thought to be caused by an arrhythmogenic event. By presenting six cases of sudden unexpected death in young female adults, we point at clinical and pathological data from the literature, which are of interest from the viewpoint of legal medicine. The incidence of MVPS in autopsy series has been reported to be about 4-5%, while clinical data hint at an incidence of about 2.5%. The presented cases suggest that even clinically benign cases of MVPS in young adults might result in sudden unexpected death. Such cases are not included in hospital based studies on the topic. This might lead to an underestimation of the fatal risk associated with the disease, even if sudden death might be a rare event in MVPS.     

Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina

Loperamide is an over‐the‐counter, μ‐opioid receptor agonist commonly used as an antidiarrheal agent. Loperamide was thought to have minimal abuse potential due to its low bioavailability and limited central nervous system activity; however, there have been increasing reports of loperamide misuse in supratherapeutic doses to achieve euphoria and/or avoid opioid withdrawal. A literature review suggests a rise in loperamide abuse was inevitable, with substantial increases in reported cases over the last decade. Five fatal cases of toxic medication use where loperamide was listed as a primary or contributory cause of death were identified at the Medical University of South Carolina. The characteristic autopsy demographics and findings are described, and the mechanisms of abuse and toxicity of loperamide are reviewed. Loperamide overdoses are a growing concern from both a forensic and clinical standpoint, and the frequency of reported cases will likely increase as awareness grows within the medical and toxicological communities.     

The correlation of childhood physical abuse history and later abuse in a group of Turkish population

Domestic violence is passed from one generation to the next, and it affects not only the victim but also the psychological states of the witnesses, and especially the psychosocial development of children. Studies have reported that those who have been the victim of or witnessing violence during their childhood will use violence to a greater extent as adults in their own families. This research examines the relationships between a history of childhood physical abuse, likelihood of psychiatric diagnoses, and potential for being a perpetrator of childhood physical abuse in adulthood among women who received psychiatric treatment and in the healthy population from Turkey. Estimates of the prevalence of childhood physical abuse vary depending on definition and setting. The frequency of witnessing and undergoing physical abuse within the family during childhood is much higher in the psychiatrically disordered group than the healthy controls. Childhood physical abuse history is one of the major risk factors for being an abuser in adulthood. The best indicator of physically abusing one's own children was found to be as physical abuse during the childhood period rather than psychiatric diagnosis. There is a large body of research indicating that adults who have been abused as children are more likely to abuse their own children than adults without this history. This is an important study from the point of view that consequences of violence can span generations. Further studies with different risk factor and populations will help to identify different dimensions of the problem.     

The Relationships Between Childhood Sexual Abuse,Social Anxiety,and Symptoms of Posttraumatic Stress Disorder in Women

The relationships between childhood sexual abuse, social anxiety, and symptoms of posttraumatic stress disorder were examined in a sample of 313 undergraduate women. Thirty-one percent of the women reported some form of sexual abuse in childhood. Women with a history of sexual abuse reported more symptoms of anxiety, distress in social situations, and posttraumatic stress disorder than other women. Women who experienced attempted or actual intercourse reported more avoidance than women with no history of abuse and women with exposure only, and more PTSD symptoms than all other groups of women. Women who experienced fondling reported more PTSD symptoms than women with no history of abuse. Pressure, age of onset of abuse, abuse by a family friend, and abuse by other perpetrators were all significant abuse characteristics in predicting adult social anxiety. Implications of these results for research and interventions are discussed.     

Forensic aspects of water intoxication: four case reports and review of relevant literature

Water intoxication (WI) is a rare condition that originates from over-consumption of water, with a potentially fatal outcome. Increased water intake (polydipsia) is followed by urination of high amount of diluted urine (polyuria) which are the main initial symptoms of WI. We present four case reports of WI. Two of them are unusual pediatric clinical cases using medical documentation and police case files, one of which is related to child abuse, and the other to a psychiatric disorder. The other two cases are fatal adult cases submitted to autopsy from a psychiatric hospital. Also, we present a diagnostic algorithm for polydipsia and polyuria before death. WI is usually seen in patients with psychiatric disorders, victims of child abuse or torture, drug abusers or it can be iatrogenically induced.     

Unexplained sudden death and the likelihood of drug abuse

The common history of drug abuse in adults with an undetermined cause of death has led us to hypothesize that chronic drug abuse increases the risk of sudden death. To begin evaluating this hypothesis, we conducted a retrospective case-control study of 61 decedents whose cause of death remained undetermined following autopsy matched one to one to a control group of pedestrians or passengers killed in motor vehicle collisions. In 21 pairs, the case subject had evidence of drug abuse but the control did not, and in 5 cases the reverse was true. Analysis showed that individuals with an undetermined cause of death are 4.2 times more likely to have evidence of drug abuse than are victims of a motor vehicle collision.     

STATE CHILD EMOTIONAL ABUSE LAWS: THEIR FAILURE TO PROTECT CHILDREN WITH GENDER IDENTITY DISORDER

Emotional abuse of children with Gender Identity Disorder by parents is very difficult to identify and prevent. State investigators of abuse and neglect often have a hard time determining if the reasons for mental illness and psychological harm in children are due to the actions of their parents, or if they stem from other sources. Once identified, it becomes even harder to prove in court for purposes of ordering services or removing the child from the home if the abuse is severe enough. With children who are gender non‐conforming, this task becomes exponentially more difficult due to the low prevalence rate, discrimination, stereotypes, and a parent's right to bring up their child as they choose. These youth face discrimination and violence in school, work, their communities, and also within their own families. Emotional abuse statutes are too vague to protect youth who are gender non‐conforming. The vague and unclear laws lead to inconsistency in the application of the law and lack of protection of the children because judges and investigators are not aware of how parent's actions harms youth with gender identity disorder. Therefore, states should adopt the model statute within this Note which defines specific actions by parents which would not qualify as abuse when involving gender conforming youth but qualifies as abuse for children with gender identity disorder. Many states already have statutes which define physical abuse, sexual abuse and abandonment by specific actions by parents towards their children. This proposal will enable both the state and the judges to properly identify victims with gender identity disorder of emotional abuse and provide for their protection.     

History of Traumatic Abuse and HIV Risk Behaviorsin Severely Mentally Ill Substance Abusing Adults

Epidemiological studies in the United States estimate HIV seroprevalence rates ranging between 4% and 23% for serious mentally ill adults (SMIA; i.e., schizophrenia, bipolar disorder, and other chronic disorders with psychotic features), with substantially greater estimates for risky sexual behaviors. Among the most consistent factors linked to HIV risk in non-SMIA populations is a history of emotional, physical, or sexual abuse. The current study examined the intersection of abuse history and HIV sexual risk behavior in SMIAs with a group of men (n = 64) and women (n = 115) recruited from eight geographically diverse and representative clinical sites around Florida. A cross-sectional interview revealed a high prevalence of alcohol and other drugs problems, as well as a history of emotional, physical, or sexual abuse in 75% of the participants, with 68% of these reporting multiple types of abuse. Compared to nonabused counterparts, those with a history of abuse reported significantly greater: (a) lifetime and current psychiatric symptoms, (b) recent unprotected sexual intercourse, and (c) crack cocaine, heroin, and marijuana use. No gender differences were detected in the associations of abuse history and sexual risk behaviors. These results underscore the need for HIV prevention efforts targeted to SMIAs and the critical importance of addressing abuse history in interventions with this underserved population.     

Acute cardiovascular fatalities following cannabis use.

We report six cases of possible acute cardiovascular death in young adults, where very recent cannabis ingestion was documented by the presence of tetrahydrocannabinol (THC) in postmortem blood samples. A broad toxicological blood analysis could not reveal other drugs. Similar cases have been reported in the literature, but the toxicological analysis has been absent or limited to urine samples, which represent a much broader time window for cannabis intake. This paper presents six case reports, where cannabis alone was detected in blood. Further, an overview over previously published cases, clinical trials and possible patho-physiological mechanisms are presented.     

Medical Evidence and Expert Testimony in Child Sexual Abuse

Expert medical testimony in child sexual abuse cases can be critical to the outcome of a legal case. This article will review the development of the medical knowledge and clinical expertise in child sexual abuse. Since the passage of mandatory child abuse reporting laws, the forensic medical examination of a child for evidence of sexual abuse has become standard. Until recently, many myths regarding female genital anatomy existed but were based primarily on dogma and lack of empirical research. Over the past 25 years, many research studies and accumulating clinical evidence have expanded medical knowledge and debunked old myths. Physical evidence, even in cases of alleged genital or anal penetration is rare. Sexually transmitted infections are also uncommon and often require medical interpretation as to their significance in a prepubertal child. Specialized medical knowledge, training, and clinical expertise have developed in order to evaluate children presenting with allegations of sexual abuse. Such medical expertise provides invaluable service to courts. We review criteria for evaluating such expertise in light of current medical practice.     

Current psychopathology in previously assaulted older adults

Older adult women age 55+ years (N = 549) were interviewed as part of a population-based epidemiological research study of lifetime experiences with physical and sexual assault and current mental health problems. Although overall rates of psychopathology were low, producing very small cells for comparison, women who reported experiencing physical assault an average of 28 years previously were more likely to present with past year substance abuse, depression, and avoidance and reexperiencing symptoms of posttraumatic stress disorder (PTSD) than those with no previous physical or sexual assault. Women who reported experiencing sexual assault an average of 50 years previously were more likely to present with autonomic arousal and avoidance symptoms of PTSD than those with no prior sexual assault. The aforementioned findings should be considered with caution, however, as sample cell sizes were minimal for all but the PTSD symptom subtypes. Mental health service implications for older adults are discussed.     

Sudden unexpected death in a patient with splenic sequestration and sickle cell-beta+-thalassemia syndrome

Acute splenic sequestration crisis is a rare disorder that usually occurs in children, with sickle cell anemia, who are under the age of five years. A few cases have been described in adults with heterozygous sickle cell syndromes. Though this entity can be fatal there have been no reported cases associated with sudden death. We describe a case of sudden, unexpected death, associated with splenic sequestration, in a 29-year-old African-American man with undiagnosed sickle cell-beta-thalassemia syndrome.     

Relationships between the deinstitutionalization of healthcare for patients with mental disorder, substance abuse, and isolated death

Isolated death (ID) (i.e., dying alone without anyone noticing for several days) has been suggested to be related to social isolation, mental disorder, and alcohol and/or drug abuse. A major transfer of patients with a mental disorder and/or alcohol and/or drug abuse from institutionalized care to treatment as outpatients has been enacted in Sweden during the past decade. On the basis of the assumption that such deinstitutionalization is likely to result in increased social isolation, our working hypothesis was that the incidence of ID among patients belonging to these categories has increased in Sweden. The present study involved all deaths subjected to a medicolegal examination in Stockholm County (with a population of approximately 1.9 million people) during the period 1992-2000. The pattern of ID (defined as cases involving a postmortem delay between death and discovery of at least 1 week), as well as the incidence of fatalities subjected to medicolegal examination with a record of mental disorder and/or alcohol and/or drug abuse was evaluated. Throughout this period, the proportion of the deceased with a record of a mental disorder was high among all the cases examined and higher still among the cases of ID, especially among those younger than 65 years of age. There was a rather limited increase in the incidence of ID and a much more pronounced increase in the number of former psychiatric patients whose deaths were subjected to medicolegal examination, but did not satisfy the criteria for ID. A record of alcohol and/or drug abuse was more common than a diagnosis of mental disorder among both the males and females who died at an age of less than 65, with a clear difference between the cases of ID and non-ID in the case of men. There was no significant increase in incidence over the course of this study. Thus, this study reveals a slight increase in the number of IDs and a more pronounced increase in the number of medicolegal examination of non-IDs of individuals with a record of a mental disorder.     

Child abuse reporting trends: an unprecedented threat to confidentiality

Some recent interpretations of the child abuse laws are creating serious and unprecedented erosions of therapist/patient confidentiality. In contrast to the Tarasoff decisions and laws, the child abuse statutes introduced a new element of mandatory reporting which permits no discretionary alternatives and presents prospects of criminal penalties for failure to report. A recent development suggests a possible requirement for therapists to violate confidentiality for the sole purpose of punishing perpetrators. Overinterpretations of the laws by some child protective services have led to recommendations that long past child abuse must be reported, even when no current child is in danger. The California Attorney General's Office has issued a clarification stating that the child abuse statute refers to children and not to adults molested as children. A survey of forensic psychiatrists and psychologists shows that most perceived an ethical problem in reporting adults molested as children when no child is presently in danger, and the purpose of the report is solely for maximal legal self-protection. The survey indicates that fears induced by rigid and intimidating child abuse laws can influence therapists to act in ways most consider unethical. Recommendations are made for improving the current child abuse laws so that they accomplish their goals more effectively.     

Medical examination of sexually abused children: medico-legal value

The Department of Forensic Medicine (forensic pathology and clinical forensic medicine), Aarhus, Jutland, Denmark, performs examinations of children suspected to have been sexually abused when reported to and requested by the police in Jutland, Denmark. Jutland covers an area of 210,000 km2 with about 300,000 inhabitants in Aarhus. A colposcope initially equipped with an Olympus camera, but now with a video camera attached has been used since 1994. Since 1994 the department has performed more than 100 examinations of children suspected of having been sexually abused. A preliminary study was taken to evaluate all cases from 1995 including the legal outcome. RESULTS: The material included 34 cases with three boys, mean age 11 years, and 31 girls, mean age 8 years, at the time of the examination. The sexual abuse events were fondling including penetration of the vagina, vaginal (14), anal (7), and oral (5) intercourse as well as cunnilingus and nontouching abuses. The medical examination was most often performed more than a week after the abuse. The examination revealed normal findings in 23 cases, nonspecific findings including erytherma in 13 cases, and in only one child was a traumatic lesion with rupture of the hymen seen. The perpetrators were above 25 years of ane and were family members or someone known to the child. Nine perpetrators were convicted at court, of whom three admitted having abused the child. CONCLUSION: A medical examination in cases of sexual child abuse seldom provides a legal proof of sexual abuse. The most important is the story told by the child. Therefore, the examination is a supplement which may support or remain neutral to the story told by the child.     

The use of multiple informants to assess children's maltreatment experiences

Most researchers rely exclusively on the reports of protective service workers to determine children's abuse history. In this report, information about children's maltreatment experiences is obtained from protective service workers and three supplementary sources of data: parents, medical records, and clinical observations. Fifty-six children from 34 families receiving protective services for verified reports of physical abuse, neglect, sexual abuse, and/or emotional maltreatment participated in the study, with most children known to have experienced more than one type of abuse. The supplementary data provided important information about the range and severity of children's maltreatment experiences. Review of the parent and medical record data led to identification of 28 children who had additional types of maltreatment experiences that were not reported by their protective services workers—nine cases of physical abuse, two cases of neglect, five cases of sexual abuse, and 12 cases of emotional maltreatment. Supplementary data also revealed information about incidents of specific types of abuse that were more severe than those reported by the children's protective service workers in an additional 24 cases. A method was devised to synthesize information provided from the different sources of data examined in this report to derive 0–4 point ratings of four categories of maltreatment experiences: (1) physical abuse, (3) neglect, (3) sexual abuse, and (4) emotional maltreatment. The Kappa reliability coefficients for each of these scales were .88, .73, .83, and .90, respectively. Data demonstrating the relationship between these maltreatment ratings and various indices of the children's socioemotional and cognitive functioning were also presented to provide preliminary support for the validity of these scales. The findings from this study suggest that multiple sources of data should be examined in order to obtain accurate assessments of children's maltreatment experiences, and that independent raters can synthesize discrepant data to obtain reliable and valid estimates of children's abuse history. Clinical and methodological issues relevant to the improved assessment of children's maltreatment experiences are also discussed.     

PARTNER ABUSE AND GENERAL CRIME: HOW ARE THEY THE SAME? HOW ARE THEY DIFFERENT?*

Both partner abuse and general crime violate the rights and safety of victims. But are these phenomena the same or are they distinct, demanding their own research and intervention specialties? Are per‐ sons who abuse their partners the same people who commit other criminal behavior? Do partner abuse and general crime share the same correlates? We investigated these questions in a birth cohort of over 800 young adults, by testing whether a personality model known to predict general crime would also predict partner abuse. Personality data were gathered at age 18, and self‐reported partner abuse and general criminal offending were measured at age 21. Results from modeling latent constructs showed that partner abuse and general crime represent different constructs that are moderately related; they are not merely two expressions of the same underlying antisocial propensity. Group comparisons showed many, but not all, partner abusers also engaged in violence against nonintimates. Personality analyses showed that partner abuse and general crime shared a strong propensity from a trait called Negative Emotionality. However, crime was related to weak Constraint (low self‐control), but partner abuse was not. All findings applied to women as well as to men, suggesting that women's partner abuse may be motivated by the same intra‐personal features that motivate men's abuse. The results are consistent with theoretical and applied arguments about the “uniqueness” of partner violence relative to other crime and violence.     

Explanations for violent behaviour—An interview study among forensic in-patients

The alleged relation between mental disorder and violent criminal behaviour has been investigated mainly from an epidemiological perspective. Population-based registry studies have shown that violence occurs more frequently among people with mental disorders, like schizophrenia and bipolar disorder, compared with control subjects, but that the increased risk is largely mediated by drug abuse and socio-economic deprivation. The aim of this study was to explore how patients who have committed violent or sexual crimes and have been sentenced to forensic psychiatric care by a Swedish court of law construed their criminal actions in terms of causes. Forty-six participants from six different Swedish forensic psychiatric clinics were included in the study. A semi-structured interview study was conducted and the data was analysed using a thematic analysis. A large group of the participants did not believe that the mental disorder played any role in the criminal events. Contributing causes that were mentioned were drug abuse and social factors.     

The role of adolescent physical abuse in adult intimate partner violence

This study's primary aims were to examine whether a sample of young adults, aged 23 to 31, who had been documented as physically abused by their parent(s) during adolescence would be more likely to aggress, both physically and verbally, against their intimate partners compared with nonabused young adults and whether abuse history was (along with other risk factors) a significant predictor of intimate partner physical and emotional violence perpetration or victimization. In this longitudinal study, 67 abused and 78 nonabused adults (of an original sample of 198 adolescents) completed the Modified Conflict Tactics Scale and the Jealousy and Emotional Control Scales. Nonabused comparison adolescents were matched for age, gender, and community income. As adults, participants with abuse histories had significantly higher rates of intimate partner physical violence and verbal aggression than did comparison participants. Multivariate logistic regressions indicated that adults with histories of physical abuse were more than twice as likely to be physically violent and almost six times more likely to be verbally aggressive to their intimate partners than were comparison participants. Having had an alcohol use disorder, being married to or living with a partner, and perceiving one's partner as controlling were also significantly associated with physical violence. Jealousy and feeling controlled by one's partner were also significant predictors of verbal aggression. These findings underscore the importance of preventing adolescent abuse as a means of decreasing the incidence of intimate partner physical violence in adulthood.